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Laparoscopy complications veress

Access to abdominal cavity in Laparoscopy is often associated with various injuries. Debate about Open Vs Verss needle access is still not settled. This presentation highlights the literature review, possible problems associated with abdominal wall access through Veress needle and their management.

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1. Extra-peritoneal gas insufflation Failure to introduce the Veress needle into the peritoneal cavity may produce extra-peritoneal emphysema. This occurs in about 2% of cases.

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1. Extra-peritoneal gas insufflation The diagnosis is made by palpation of crepitus caused by bubbles of CÓ2 under the skin.. If this is recognized early, the gas may be allowed to escape and the needle re-introduced through the same or another site.

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Extra-peritoneal gas . 1 insufflationIf the complication is not recognized during the introduction of gas, the typical appearance of extra-peritoneal gas may be recognized when an attempt is made to introduce the telescope.It is always essential to view through the telescope during its insertion through its cannula.

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Extra-peritoneal gas . 1 insufflation The typical spider-web appearance caused by pre-peritoneal insufflation will be seenwhen the telescope reaches the end of the cannula and furtherstripping of the peritoneum by the tip of the telescope avoided.

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Extra-peritoneal gas . 1 insufflationThe laparoscope should be withdrawn and attempts made to express the gas.The needle may then be re-introduced through the same or another site.Alternatively the trocar and cannula may be introduced by

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Extra-peritoneal gas insufflation . 1 The aspiration test and the high insufflation pressure will make it obvious that the needle is sited incorrectly in which case it should be withdrawn and re-sited.

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2. Injury to gastro-intestinal tract Certain conditions may predispose to injury by the Veress needle.  These include :1. Distension of the gastro-intestinal tract or2. Adhesions of bowel to the abdominal wall.

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2. Injury to gastro-intestinal tractPenetration of the stomach may occur when an upper abdominal site of insertion is chosen or the stomach is distended during induction of anesthesia.

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2. Injury to gastro-intestinal tractGastric distension may also occur if anesthesia is maintained with a mask and should be suspected if there is upper abdominal distension or increased tympanism.In this case the stomach should be aspirated with a naso -gastric tube.

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2. Injury to gastro-intestinal tractThe diagnosis of gastric perforation by the Veress needle may be made when the patient belches gas.The laparoscope should be introduced and the stomach inspected carefully.

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2. Injury to gastro-intestinal tractProvided the stomach wall has not been torn, no surgical treatment is necessary but a broad spectrum antibiotic should be given.If the stomach has been torn, surgical repair either by laparotomy or laparoscopy is mandatory.

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2. Injury to gastro-intestinal tract Aspiration following initial insertion of the needle should permit early recognition of perforation of the bowel but it is not fool-proof.

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2. Injury to gastro-intestinal tractBowel penetration should be suspected if there is1.Asymmetric abdominal distension,2.Belching,3.Passing of flatus or a fecal odour.

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2. Injury to gastro-intestinal tractThe induction of pneumoperitoneum should be stopped and the needle re-sited to introduce the pneumoperitoneum correctly.The gastro-intestinal tract should be examined carefully for perforation.

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2. Injury to gastro-intestinal tractIt is important that both sides of the bowel be examined as the exit wound may be larger than the entry wound.Fecal soiling demands immediate laparotomy and repair of the bowel.

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2. Injury to gastro-intestinal tract A simple needle penetration requires no treatment but the patient should be kept under observation and given broad spectrum antibiotics.

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Bladder injury . 3Routine catheterization of the bladder and propersitting of the needle should prevent bladder penetration.

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Bladder injury . 3Ifpneumaturia is noted the needle should be partially withdrawn and the creation of pneumoperitoneum continued.

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Bladder injury . 3The bladder peritoneum should be carefully inspected to ensure that no significant injury has been caused.The treatment of a simple puncture is conservative with postoperative bladder drainage.

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Blood vessel injury . 4 The Veress needle may penetrate:1. omental or2. mesenteric vessels or3. any of the major abdominal or pelvic arteries or veins.

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Blood vessel injury . 4Minor vascular injuries involvingthe omental or mesenteric vessels are difficult to prevent as it is impossible to ensure that the omentum is not close to the abdominal wall during blind insertion of the insufflating needle.

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Blood vessel injury . 4 Injury may be suspected if:1. blood returns up the open needle or if :2. free blood is seen in the peritoneal cavity after insertion of the laparoscope.

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Blood vessel injury . 4Ifblood returns up the needle and the patients condition is stable, the site of injury may be investigated laparoscopically.The needle should be left in place and a 5 mm laparoscope introduced through a suprapubic cannula.

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4. Blood vessel injuryMinimal bleeding may usually be controlled by bipolar coagulation or a laparoscopic suture.Laparotomy is not usually necessary except in the case of injury to the superior mesenteric artery.Such injury requires repair by a vascular surgeon (Bassil et al, 1993)

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4. Blood vessel injury  Injury to the major vessels may be prevented by:1. Lifting the abdominal wall,2. Angling the needle towards the pelvis once the initial thrust through the fascia has been made and by3. Inserting only as much of the needle as necessary.

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4. Blood vessel injuryThin patients and children are at particular risk of this injury.Withdrawal of blood on aspiration following insertion of the needle should allow early detection of blood vessel injury.

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4. Blood vessel injuryIf injury to a vessel such as the aorta, inferior vena cavaor common iliac vessel is suspected, the needle should be left place to mark the site of the injury and laparotomy performed through a mid-line

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4. Blood vessel injuryThere is usually a large haematoma which obscures the site of the injury.The aorta should be compressed with a clamp or hand until a vascular surgeon arrives to perform definitive surgery.

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4. Blood vessel injuryDramatic collapse may result from penetration of a major vessel but the bleeding may not be immediately evident if it is retro-peritoneal.The loose areolar tissue anterior to the aorta can allow accumulation of a considerable amount of blood before frank intra-abdominal bleeding is seen.

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4. Blood vessel injuryA thorough search must be made to determine the extent of vessel damage.This includes retraction of bowel to expose the aorta above the pelvic brim which is the most common site of perforation.

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4. Blood vessel injury Failure to do search may result in continued bleeding and formation of a largehaematoma leading to a second episode of shock some hours later

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Puncture of liver or spleen . 6 The liver or spleen may be punctured by the Veress

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Gas embolism . 5Intravascular insufflation of gas may lead to gas embolism or even death.This can only happen if the penetration by the Veress needle goes unrecognized and insufflation commences.

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Gas embolism . 5It should be prevented by routine use of the aspiration test.The patient should be turned on to the left lateral position and,If immediate recovery does not take place, cardiac puncture performed to release the gas.

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Open vs. Closed Access Numerous studies have shown no clear benefit for one over the other The incidence of bowel and vascular injury for both are between 0.0 and 0.1% Risk factors for both included previous surgery, thin habitus, distention, and obesity JOGC 2007;193May:433-447

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Safety and Closed Access (Veress (Needle Initial pressure > 10 mm Hg Access at Palmer’s Point with prior lower abdominal incisions (or use open technique)  When using Palmer’s Point, always decompress stomach with OG tube  Do not use Palmer’s Point in presence of upper abdominal incisions Use Palmer’s Point for very thin and very obese patients For thin patients and umbilical access, angle needle 45 degrees caudal and for obese patients, introduce needle perpendicular to the skin Do not waggle needle Abort umbilical site after 3 failed attempts Use pressure instead of volume endpoint (20 mm Hg) Check for access injuries upon entry and closure JOGC 2007;193May:433-447

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(Safety and Open Access (Hasson Avoid access through previous surgical scar Use more lateral access in such casesEnter peritoneal cavity under direct visionCheck for access injuries on entry and closure